Suture Rupture in Acromioclavicular Joint Dislocations Treated With Flip Buttons

Case Report

Suture Rupture in Acromioclavicular Joint Dislocations Treated With Flip Buttons Pierorazio Motta, M.D., Alberto Maderni, M.D., Laura Bruno, M.D., and Umberto Mariotti, M.D.

Abstract: Acute acromioclavicular joint dislocations (ACDs) may be treated arthroscopically with flip buttons. This extra-articular fixation is easy to implant and is well tolerated. Between 2007 and 2009, 20 ACD patients (2 women and 18 men; mean age, 32 years) had surgery by the arthroscopic TightRope technique (Arthrex, Naples, FL). The main complication of this technique that has been reported is the partial loss of reduction at follow-up due to clavicular osteolysis under the superior flip button. We describe 4 cases with loss of reduction due to rupture of the sutures running across the buttons: 2 women with joint hyperlaxity and acute Rockwood grade IV ACD and 2 men, heavy manual workers, with joint hyperlaxity and acute Rockwood grade IV ACD. The use of flip buttons might not be indicated in patients with joint hyperlaxity because they are able to obtain immediate stability only on the vertical plane and not on the horizontal plane. Anteroposterior movements of the acromioclavicular joint might rub the suture against the bone tunnels leading to wear and cutting.

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o date, there has been no surgical repair of coracoclavicular ligaments able to restore the native ligament stiffness.1-5 More recently, some authors have focused on the importance of surgical reconstruction of the coracoclavicular ligaments and acromioclavicular joint (ACJ).6-9 Although the pullout strength of the flip button repair is very close to that of the native ligaments,10 the native ACJ stiffness cannot be reached.11,12 Between 2007 and 2009, 20 patients (2 women and 18 men; mean age, 32 years) underwent surgery with the TightRope (TR) technique (Arthrex, Naples, FL) for acute acromioclavicular joint dislocation (ACD) within 15 days of trauma. Four of them

had joint hyperlaxity (ⱖ4 points according to the Beighton scale).13 The international literature reports that the main complication of the TR system is partial loss of reduction at follow-up, due to clavicular osteolysis under the superior flip button.14,15 To our knowledge, this is the first time suture rupture has been reported as a complication. We report suture failure in 4 cases even if, as recommended by the technique, the patients wore a shoulder immobilizer (UltraSling; Donjoy, Vista, CA) for 4 weeks to protect the ACJ repair. CASE REPORTS Patient 1

From the Shoulder Unit, The CTO Orthopedic and Trauma Center, Turin, Italy. The authors report no conflict of interest. Address correspondence and reprint requests to Pierorazio Motta, M.D., Shoulder Unit, The CTO Orthopedic and Trauma Center, Via Zuretti 29, 10126 Turin, Italy. E-mail: pierorazio.motta@ fastwebnet.it © 2011 by the Arthroscopy Association of North America 0749-8063/10416/$36.00 doi:10.1016/j.arthro.2010.09.009

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A 31-year-old woman fell on her left shoulder, resulting in acute pain and deformity. Clinical evaluation indicated joint hyperlaxity and ACJ deformation. Standard radiographic examination confirmed the clinical diagnosis evidencing a Rockwood grade IV ACD. Arthroscopic treatment was given 10 days later. Surgery was carried out with the TR system (6-mm clavicular button and No. 5 Arthrex FiberWire). The

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 27, No 2 (February), 2011: pp 294-298

SUTURE RUPTURE IN ACJ DISLOCATION

FIGURE 1. Patient 1 with grade IV ACD. Postoperative radiograph shows reduction with flip button (TR device).

patient was placed in the beach-chair position, without any arm traction, under general anesthesia, and the ACD was reduced after drilling of bony tunnels. Fluoroscopic control at the end of the operation showed that the ACJ had been correctly reduced (Fig 1). The patient was fitted with a shoulder immobilizer for a 4-week period; removal of the sling was allowed only for washing and elbow flexion/extension exercises. Twenty-eight days after surgery, the patient noticed a sudden painless recurrence of the shoulder deformity. The following day, at the outpatient department control, she reported that she had had no traumatic events that might have justified this occurrence. Standard radiographs and a complete clinical examination confirmed a Rockwood grade IV ACD. Although the clavicle flip button was observed to be slightly below the original position because of bone resorption, the coracoid button position had remained the same (the distance between the 2 flip buttons was, therefore, increased) (Fig 2). The clinical evaluation showed that she had ACJ instability on both the vertical and the horizontal planes. Two years later, she reported pain localized on the clavicular FiberWire knot and was referred for surgery again. We removed only the knot, which was found as a free body in the soft tissues and was no longer connected to the buttons. There was no evidence of infection.

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wood grade IV ACD was diagnosed radiographically. Although she was informed that we had observed ACD recurrence in another patient we had operated on, she opted for surgery because she wanted to return to sport activities and did not accept shoulder deformity. Consequently, the team decision was to operate on her 8 days later using the same surgical position and postoperative rehabilitation as mentioned previously. Passive elevation was allowed up to 90° after 30 days, so as to promote a gradual recovery of the articulation activity; full range of motion was permitted at 40 days, with weight lifting at 3 months. The arthroscopic TR surgical technique was used (10-mm clavicular button and No. 5 FiberWire) and acromioclavicular fixation was carried out with 2 resorbable pins (TRIM-IT Drill Pin; Arthrex). In this case we first reduced the ACJ with 2 temporary Kirschner wires, which were substituted with 2 resorbable pins after having drilled the bony tunnels and TR positioning. Intraoperative radiography showed correct positioning of the flip buttons and a good ACJ reduction on the vertical plane, whereas a slight posterior dislocation of the clavicle could still be seen (Fig 3). Five months postoperatively, the patient reported a sudden painless shoulder deformity. Clinical evaluation confirmed AC instability on both the vertical and horizontal plane and the radiograph indicated ACD recurrence (Rockwood grade IV) (Fig 4); the clavicle flip button was slightly below the original position, because of bone resorption. The coracoid button position had not changed. No further surgery was done, and at most recent follow-up, the patient had reduced

Patient 2 A 39-year-old woman had a bicycle accident and reported acute pain in her left shoulder. On clinical evaluation, there was joint hyperlaxity and a Rock-

FIGURE 2. Patient 1 with clavicular cylindrical tunnel–shaped bone reabsorption. One-year follow-up radiograph shows acromioclavicular grade IV dislocation recurrence.

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P. MOTTA ET AL. on within 10 days (the same procedure as patients 2 and 3). Fluoroscopic control at the end of the operation showed that the ACJ had been correctly reduced. Four months later, he had sudden and complete recurrence of the shoulder deformity. At present, he reports being disappointed with his shoulder deformity but has no painful or disabling symptoms. DISCUSSION

FIGURE 3. Patient 2 with grade IV ACD. Postoperative radiograph shows a good ACJ reduction on the vertical plane but a slight posterior dislocation of the clavicle.

Clavicular osteolysis was observed in all patients, with partial loss of reduction in 5. This finding is in agreement with Murena et al.14 and Boileau et al.,15 who report cases of distal migration of the flip button within the upper third of the clavicle; the first TR device (case 1) had a 6.5-mm-diameter clavicular button with a 4-strand suture configuration of No. 5 interlaced FiberWire. The cannulated drill had a 4-mm diameter. The manufacturer modified the clavicular button to a 10-mm-diameter slightly curved shape to increase the contact surface between the clavicular button and the clavicle. The use of a larger clavicular button in our last 3 cases (10 mm v 6 mm) protected the clavicle from osteolysis. Arthroscopy allows for adequate circumferential access and preparation of the coracoid

her sports activities but returned to normal everyday life. Patient 3 A 25-year-old man, a heavy manual worker, had a motocross accident with consequent Rockwood grade IV ACD, confirmed radiographically. Clinical evaluation showed joint hyperlaxity, and he had surgery 11 days later with the same procedure and postoperative rehabilitation as patient 2. Fluoroscopic control at the end of the operation showed that the ACJ had been correctly reduced. Five months later, he too reported a sudden and complete recurrence of the shoulder deformity. Clinical and radiographic examinations confirmed the recurrence. At present, the patient carries out his normal everyday activities and amateur sports but occasionally has shoulder pain and fatigue. Patient 4 A 35-year-old man fell off his bicycle and was referred to our emergency department. Clinical evaluation showed joint hyperlaxity, and radiographs evidenced a Rockwood grade IV ACD. He was operated

FIGURE 4. (A) Patient 2 had recurrence of acromioclavicular grade IV dislocation 5 months after surgical reconstruction. (B) Patient 2 detail showing clavicular trapezoid-shaped bone resorption.

SUTURE RUPTURE IN ACJ DISLOCATION process and positioning of the flip button in the anatomic center of the coracoclavicular ligament insertion. No neurovascular injury was observed. Indeed, the closest point to the axillary nerve is 29.3 mm from the anteromedial aspect of the base of the coracoid.16 Boileau et al.15 reported a superficial infection of the superior portal, and Vansice and Savoie17 reported a local infection on the knot in 2 patients. In our series only case 1 had a skin irritation due to the knot. Lateral migration of the subcoracoid EndoButton (Ethicon, Somerville, NJ) was described by Boileau et al.15 No dislocation of the flip buttons from the original position was observed in any of our patients. When the surgeon was operating on patient 1, the clavicle and coracoid bony tunnels were drilled while maintaining only a partial manual reduction of the ACJ. The ACJ was then anatomically reduced by pulling the interlaced FiberWire between the 2 flip buttons and was then fixed with a knot. Therefore, after reduction, the clavicular and coracoid tunnels were not in the same direction as they were when drilled. This might be responsible for the windshieldwiper effect as a result of the abrasive forces on the tunnel wall, leading to suture friction and rupture. In an attempt to overcome this difficulty, we modified our technique in the other 3 patients. We first fixed the ACJ reduction with 2 Kirschner wires and then drilled the 2 bony tunnels (clavicle first, then coracoid) to ensure remaining in the same direction. The Kirschner wires were then substituted with 2 resorbable TRIM-IT Drill Pins (Arthrex) to increase surgical reconstruction stiffness and reduce the windshield-wiper effect. The ACD recurrence occurred later in the last 3 patients than in the first (5 months, 5 months, and 4 months v 1 month) and with a trapezoid-shaped resorption of the clavicular tunnel (Fig 4), instead of the cylindrical tunnel shape seen in patient 1 (Fig 2). Although the direction of the bony tunnels is not the only cause of rope rupture, it can most likely explain the rapid failure of the system without modifications in the shape of the bone tunnel. The drill pins are able to help maintain temporary ACJ stability, even if they are not stiff enough to prevent a long-term windshieldwiper effect. We observed that the use of a larger-size clavicular button in the last 3 cases (10 mm v 6 mm) did not influence the suture rupture. According to Wellmann et al.,11 the flip button provides a more anatomic reconstruction than does the extra-articular loop (synthetic or tendon) and does not

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lead to anterior clavicular dislocation. Clavicular rotations are permitted, whereas other metallic devices (e.g., Bosworth screw) are too stiff and may lead to recurrent deformity in up to 35% of cases.18 Muscle transfers can result in nonunion between the coracoid and the clavicle.19 Mazzocca et al.8 reported that the coracoacromial ligament transfer (Weaver-Dunn procedure) with augmentation has been shown to have no effect on anteriorposterior translation of the distal clavicle. Debski et al.7 reported that the intact coracoclavicular ligaments cannot compensate for loss of capsular function of the ACJ. We are in agreement with this finding, especially in patients with joint hyperlaxity. Indeed, in line with Tennent and Richards,20 when we applied this technique to 11 patients affected by distal clavicular fracture, associated with complete coracoclavicular ligament lesion and an intact ACJ, the outcome was successful and no complications were reported. Some authors have recently advocated the use of 2 flip buttons to achieve better stiffness (double TR)11,12 or use of allograft in a modified device (GraftRope; Arthrex) to obtain a better biological response.21 To our knowledge, this is the first clinical report documenting the complication of suture rupture when using the TR technique. On the basis of our results, we are of the opinion that the TR technique is best not used in patients with joint hyperlaxity. However, we have started to use the 4 –flip button device to improve surgically reconstructed ACJ stiffness12 and tendon allograft to repair the ACJ.6 Therefore further research is ongoing and findings will be reported. REFERENCES 1. Motamedi AR, Blevins FT, Willis MC, McNally TP, Shahinpoor M. Biomechanics of the coracoclavicular ligament complex and augmentations used in its repair and reconstruction. Am J Sports Med 2000;28:380-384. 2. Costic RS, Labriola JE, Rodosky MW, Debski RE. Biomechanical rationale for development of anatomical reconstructions of coracoclavicular ligaments after complete acromioclavicular joint dislocations. Am J Sports Med 2004;32:19291936. 3. Jari R, Costic RS, Rodosky MW, Debski RE. Biomechanical function of surgical procedures for acromioclavicular joint dislocation. Arthroscopy 2004;20:237-245. 4. Harris RI, Wallace AL, Harper GD, Goldberg JA, Sonnabend DH, Walsh WR. Structural properties of the intact and reconstructed coracoclavicular ligament complex. Am J Sports Med 2000;28:103-108. 5. Harris RI, Vu DH, Sonnabend DH, Goldberg JA, Walsh WR. Anatomic variance of the coracoclavicular ligaments. J Shoulder Elbow Surg 2001;10:585-588. 6. Grutter PW, Petersen SA. Anatomical acromioclavicular ligament reconstruction: A biomechanical comparison of reconstructive techniques of the acromioclavicular joint. Am J Sports Med 2005;33:1723-1728.

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